Collar Reconstruction During Robotic Prostate Surgery Speeds Recovery of Urinary Control

May 12, 2007— Thousands of men who opt for surgical removal of the prostate as their primary treatment for prostate cancer have to face the risk of post-operative urinary incontinence.

Now a team of urologic surgeons at NewYork-Presbyterian Hospital/Weill Cornell Medical Center has devised what they describe as a simple, effective means of reconstructing key anatomical structures that ensure continence.

The new method hastens recovery of urinary continence for patients with early-state, localized, non-aggressive tumors, they say. Ptobably, it will have no impact on the small minority of patients who endure long-term failure to recover urinary continence.

"This modification helped in the early return of continence," writes lead researcher Dr. Ashutosh K. Tewari, director of robotic prostatectomy and outcomes research at NewYork-Presbyterian/Weill Cornell and the Ronald P. Lynch Associate Professor of Urologic Oncology at Weill Cornell Medical College. "It is unlikely that the long-term results will be any different, but shortening the recovery time will have psychological, financial, and health-related quality-of-life benefits for the patients."

Dr. Tewari and his team describe their new procedure in the journal Urology. "Modifying existing tissues, our technique added only a few minutes to standard robotic prostatectomy, yet attained a 95 percent continence rate among patients 16 weeks after their surgeries," Dr. Tewari says.

"This is a real breakthrough in prostate cancer care, as a significant number of patients have post-prostatectomy urinary incontinence," adds senior researcher Dr. E. Darracott Vaughan, attending urologist at NewYork-Presbyterian/Weill Cornell and The James J. Colt Professor of Urology at Weill Cornell Medical College. He is also Weill Cornell's senior associate dean for clinical affairs.

"Too often, the threat of incontinence can be a key factor in a patient's decision for or against prostatectomy," Dr. Vaughan adds. "A simple intervention like this could make that choice a lot easier."

Prostatectomy involves excision (cutting out) of the prostate gland, as well as some adjacent tissue, depending on the extent and aggressiveness of the tumor.

"Unfortunately, this can weaken structures that control the retention and release of urine from the bladder, such as the puboprostatic ligaments, related muscle and other key anatomy," Dr. Tewari explains. "Together, these structures form a kind of sphincter that must remain strong and supported to maintain urinary continence."

Numerous attempts have been made to modify prostatectomy and preserve continence, but none have proven ideal. Trying to find a better way, Drs. Tewari and Vaughan reviewed 3-D videos that detailed the urological anatomy of patients who had retained full continence after prostatectomy. "We were trying to figure out what went right in those cases," Dr. Vaughan says.

Armed with those insights, they devised the new technique, modeling it first in cadaver tissues. They then tested the new procedure in 50 consecutive patients scheduled to undergo robot-guided prostatectomy for the treatment of localized prostate cancer.

The procedure added just two to five minutes to the standard prostate-removing operation.

Tewari reasoned that preservation of the puboprostatic collar during robotic surgery would help to restore early continence in men undergoing robotic prostatectomy.

"Our technique uses tissues that would normally remain behind after prostatectomy -- tissues that we can flip around and support to our advantage," Dr. Tewari explains. "We reconstruct the anterior and posterior parts of the sphincter and surgically join the bladder and the anastomosis (the gap in tissues left by prostatectomy) with the surrounding structures. In doing so, we reconstruct the major anatomical players controlling urinary continence."

"The puboprostatic ligaments, puboperinealis muscle, and arcus tendineus." he writes, "are all recognized as important for continence in men and women. This complex of ligaments, muscles, and tendineus aponeurosis acts in unison to provide continence and can be disrupted during robotic prostatectomy."

"We developed reconstructive strategies to reconnect the ligaments to the urethrovesical anastomosis, reapproximated the muscles, and fixed the distal bladder to the arcus tendineus," he writes.

The post-surgical results showed that one week after patients first had their urinary catheters removed, 29 percent were already fully continent; by six weeks, that figure rose to 62 percent; by eight weeks, 88 percent of the men were fully continent; and by 16 weeks, 95 percent had achieved continence. "No other differences were found in the operative, oncologic, or perioperative outcomes."

The researchers stressed that the men involved in the study had all been diagnosed with non-aggressive, localized cancers. "With more aggressive tumors, surgeons must often excise the tissues that we need for reconstruction, so the technique is not useful in those cases," Dr. Vaughan says.

"But those cases are relatively uncommon, so most patients who undergo prostatectomy stand to benefit from the procedure," says co-author Dr. Alexis Te, director of the Brady Prostate Center at NewYork-Presbyterian/Weill Cornell and associate professor of urology at Weill Cornell Medical College.

"The technique entails no extra cost and very little added time in the OR, although surgeons would have to be trained, of course," Dr. Tewari says. "We're confident the procedure will enhance post-prostatectomy recovery, sparing men the significant loss in quality of life that chronic urinary incontinence can bring."

Sources and Links

Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urinary Continence in Men Undergoing Robotic Prostatectomy
Urology, Volume 69, Issue 4, April 2007, Pages 726-731
Additional co-authors include Dr. Kevin Bigelow, Dr. Sandaya Rao, Dr. Atsushi Takenaka and Dr. Nasr El-Tabi -- all of the Department of Urology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and Weill Cornell Medical College.

The Urology study was funded by the Ronald P. Lynch Oncologic Endowment and the Brady Urologic Research Foundation at Cornell University. Dr. Tewari is the principal investigator of a separate research study supported by Intuitive Surgical, Inc., makers of the da Vinci Surgical System, the surgical robot used in the current study.

Competitive Awards Program Grant for Dr. Tewari
In related news, the Prostate Cancer Foundation has selected Dr. Tewari as the recipient of a grant for his work in developing procedures that would allow men to retain full sexual function after radical prostatectomy.
For more information, visit http://www.nyp.org.